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PubMed1999

[Family-centered obstetrics in Hungary].

The author has carried out a survey at hospitals in Hungary to examine how general family-centred obstetrics is, and to what extent obstetrics departments are able to meet the increasing demand for this exerted by society. In the course of the survey he focused on the characteristics of obstetrics departments, the preparation for delivery and maternity, open delivery-rooms, delivery with the partner, early mother-baby contact and rooming-in, and to what extent these operate. He describes the findings on the basis of data returned by 87 maternity departments, 81.3% of the total number of institutions in the country. The data reveals that 96.6% of wards have preparatory courses for delivery and maternity, 98.8% of open-delivery rooms welcome the partner at the delivery, early mother-baby contact is possible in 97.7% and 95.6% offer rooming-in. The study gives a comprehensive view of the present state of family-centred obstetrics offering an opportunity for everyone to re-evaluate their practices and to set up new objectives so that every mother and family can have easy access to family-centred obstetrics.

Delivery Rooms↗
PubMed1976

Importance of obstetrics in a comprehensive family practice.

Four family practices in the San Francisco Bay Area, two of which did not include obstetrics and two of which did, were examined with reference to their patient populations and to the number of families for which they provided comprehensive, continuous family care. The groups practicing without obstetrics were found to do acute care primarily and, to a lesser extent, long-term care internal medicine, with very little pediatrics or gynecology. The groups practicing with obstetrics did significantly more minor surgery, gynecology, pediatrics, and psychotherapy. During the six-week study, the group practicing with obstetrics saw five times as many patients who were members of families receiving continuous, comprehensive care from the practice under observation. Psychotherapy done by the group including obstetrics was primarily family therapy; for the other group, individual therapy. If larger studies support these findings, then important implications are suggested for training programs in family practice and for the resident deciding to enter practice.

Adult↗
PubMed2000

[Gestational diabetes: the Rennes Study of joint obstetrical and endocrinological management].

OBJECTIVE: To assess the efficacy of a co-program of care in gestational diabetes conducted by the obstetrical and endocrinological units of the Rennes South Hospital (Hopital Sud) and the possibility of adapting obstetrical care to existing risk factors. PATIENTS AND METHODS: A retrospective analysis was made of 200 cases of gestational diabetes diagnosed between January 1993 and December 1996 in the obstetrical units. RESULTS: Instrumental extraction and cesarean section were required for 13.5% and 20.5% of the deliveries respectively. Shoulder dystocia occurred in 2%. 19.9% of the infants had macrosomia and 5. 3% were small for gestational age. Neonatal morbidity required transfer to the pediatric intensive care unit for only 2.9% of the infants. Frequency of cesarean section and macrosomia correlated with poor blood glucose control and excess maternal weight for gravidic hypertension. At 3 months post-partum, glucose intolerance and non-insulin-dependent diabetes were diagnosed in 13% and 2% respectively. CONCLUSION: Systemic screening and obstetrical and endocrinological care allowed patients to prevent maternal and fetal complications in gestational diabetes and to initiate hygiene and dietary habits for the prevention of post-partum non-insulin-dependent diabetes. Obstetrical care can be adapted to risk factors such as overweight, late screening or poor blood glucose control.

Body Mass Index↗
PubMed1999

Clinical experience with management of "near-miss" cases in obstetrics.

Near-miss cases in life-threatening obstetric patients occurring over a one year period are analysed retrospectively with regards to morbidity measured in terms of hospital stay, utilisation of high dependency ward and intensive care beds and adequacy of clinical management. One-hundred and twenty two cases occurred among 9932 deliveries. Massive obstetric haemorrhage (54.2%) and hypertensive disorders of pregnancy (36.9%) were the two main diagnostic groups. Seventy one (58.2%) cases were referred from peripheral centres for obstetric management and 77 (63.1%) were not booked at this hospital for antenatal care. A majority were not ill-looking (92 cases) at the time of admission but turned for the worse in the course of labour. Interventional measures taken in clinical management were considered appropriate in all cases. Delay in instituting treatment was present in 6 cases. Remediable measures were recognised in 15 (12.3%). This study, apart from supplementing mortality audits, demonstrates that high risk obstetric patients can be triaged at the time of admission to labour wards by trained midwives and junior doctors in busy obstetric units without compromising standards of care.

Adult↗
PubMed2001

[Most of the complaints in gynecology and obstetrics care are generated by perceptions stemming from unavoidable results].

UNLABELLED: The annual rises in the cost of claims suffered by some countries had led to increases in: costs of the attention; malpractice premiums; health personnel stress level; risks for the patients with difficult problems, and lack of opportune attention. The intricate interaction between clinical state, responses variability and medical procedures flaws makes impossible stop unavoidable outcomes (UO). Though UO are not derived from negligence or inability, patients and relatives can see it as a malpractice result. OBJECTIVE: To determine the proportion of complaints generated by UO related perceptions (UORP) and their distribution in obstetric and gynecologic stages of care. MATERIAL AND METHODS: A search for claims derived from gynecologic or obstetric care was undertaken in the Medical Arbitrition National Commission (CONAMED) database, those presented between Jun. 1, 1996, and Nov. 30, 1998, were chosen. Some claims were derived directly from UORP (D-UORP claims), others were derived indirectly (UORP clamis); claims were grouped for stage of the attention in which they were originated; non D-UORP claims were grouped also by motives. RESULTS: In 625 claims (98.6% of total) was possible obtain precise information as required for the study. 79% of complaints were derived from UORP; 17% from perceptions generated for medical activities unrelated to UO (MAU-UO claims) and 4% by perception originated from care system (CS claims). 46% of complaints concerned surgical treatment, 27% medical treatment, 14% initial study, 2.1% delivery, in 10% a specific stage of the attention was not mentioned. The motives of the non D-UORP complaints were: 1) I-UORP claims; a) opportunity of the action, when the patient referred delay or inopportuneness as cause of the complaint (17%, overall); b) Professional quality, when questioned de outcomes or medical criteria (23%); 2) MAU-UO claims: a) Professional capacity when patient questions ability, or complaint of error in diagnosis (failure to diagnose or incorrect diagnosis), wrong removal, unnecessary treatment or other actions outside of the norm (13%); b) Improper information (3%); c) Inappropriate manner (0.8%); 3) CS claims: a) Resources (1%); b) Accessibility (2.9%). COMMENTS: The damage risk attributable to medical negligence is very low among patients who had received obstetrical or gynecological care, most of the complaints are UORP generated. In obstetrical care--from 1997 national statistics and described results--a benefit was procured to 1,705,161 persons and were produced 17 possible wrong attentions by professional capacity, five by improper information and one by inappropriate manner; the rest, 123 complaints, were derived from perceptions induced by UO. Undoubtedly there is low complaint registration, however, even at worst the wrong attention effect is lower than the impact attained if the possibility of economic benefit search through medical demands is not totally canceled. The damage risk derived from cost of claims is greater, as suffered on many countries. Medical associations in countries without professional liability problems must accomplish negotiations so that the legislation does not establish compensations by medical care results, the request may be based in: a) the deleterious consequences derived from cost of claims; and, b) the low probability of affecting the patients interests, in Mexico complaints derived from perceptions about the professional capacity are one in 103,022 obstetrical care attentions, the improper information derived one in 316,989 and the inappropriate manner generated one in 1,373,620. These organizations and other health related could assume the commitment to abate the foreseeable complaints and to do research on feasible forms to forecast UO, technically this must be long-range and though international collaboration.

Databases, Factual↗
PubMed2000

Current obstetrics: what neonatologists need to know.

The changes in obstetrics have led to the collection of much more physiologic data about the fetus during development. These advances are not only important to obstetricians but also to neonatologists. Unfortunately, the organizational structure of medicine has made it difficult to develop effective perinatal medical services, where both a full complement of obstetrical resources and a full complement of neonatal services are available within the same hospital service. The reasons for this are discussed. Neonatologists should use the current fetal physiologic data which are collected to develop both short and long term follow up studies in order to relate specific obstetrical findings to neonatal outcome. The advances in obstetrics have had a particular impact upon the problem of intrauterine growth retardation. This has meant that neonatologists must deal with infants born very premature who are also intrauterine growth retarded. These babies may have obstetrical data defining fetal circulatory failure and/or placental failure. It is in this arena where a knowledge of how to interpret the physiologic data collected by obstetricians about the fetus is particularly useful to neonatologists.

Fetal Growth Retardation↗
PubMed2000

[The origin of the Wilno Obstetric and Gynaecological Clinic and its roots, which reach as far back as the 18th century].

Studies carried out in libraries and archives in Wilno, Cracow, Warsaw and Gdánsk raven how the clinic of obstetrics and gynaecology was created in Wilno, describe the first years activity, and the persons who had the greatest influence on its creation and position. This clinic, which was organized by Tadeusz Burdziński and developed by Władysław Jakowicki in cooperation with Wacław Zaleski, functioned in the years 1922-1939. In its scarcely 17 years of existence this clinic had a marked presence among the Polish clinics of obstetrics and gynaecology in the Second Republic (II RP). In the author's opinion this fact can be traced back to the roots of obstetrics and gynaecology in the university in Wilno, which reach as far as the 18th century and the person of Mikołaj Regnier. For the first half of the 19th century the gynaecologists and obstetrics of Wilno includes Andrzej Matusewicz and Mikołaj Mianowski carried out their scientific activities outside the University for nearly 80 years. It seems that this activity, which lead to numerous publications, is the platform upon which rests continuous scientific tradition of obstetrics and gynaecology in Wilno and lets us see to present clinic in the University of Stefan Batory - in 21st surely century - as her heiress of that tradition.

Ambulatory Care Facilities↗
PubMedDate not supplied

Obstetric care in family practice residencies: a 5-year follow-up survey.

BACKGROUND: The percentage of family physicians delivering babies decreased from 46% in 1978 to 32% in 1992. Some family practice leaders predicted that, by the turn of the century, training for family practice obstetrics would focus primarily on those planning to work in remote or rural settings. A 1993 study found three primary factors associated with an increased incidence of future maternity care. In 1997 the Residency Review Commission (RRC) stipulated that all family practice residencies have at least 1 family physician serve as an intrapartum attending physician for family practice resident deliveries. METHODS: Using an instrument similar to that used in 1993, we surveyed the directors of 462 family practice residencies in the United States. Sixty-four percent (295) of the program directors responded to one of two mailings. RESULTS: Compared with the survey published in 1993, program directors estimated a 16% increase in the number of residents who included obstetrics in their first practice after residency. Factors associated with increased obstetric participation included having only family physician faculty supervise uncomplicated deliveries and having family physician faculty who could perform other perinatal procedures. Programs that had 4 or more family physician faculty doing obstetrics and those that had more than 10 deliveries per month also produced more physicians who provided maternity care. Fifty-three percent of residencies that did not have family physician faculty attending deliveries before 1997 now meet this RRC requirement. CONCLUSIONS: This study shows that, according to their program directors' estimates, more family practice residents are including obstetrics in their first practice after residency compared with 5 years ago. The new RRC regulation was associated with more than 50% of previously noncompliant programs adding or retraining faculty who could attend resident deliveries within 12 months of the inception of the new policy.

Family Practice↗
PubMed2002

Associations between ethnicity and obstetric intervention in New Zealand.

AIMS: To determine whether the lower rates of obstetric interventions in Maori and Pacific Island women from the New Zealand Ministry of Health obstetric procedures report in 1999 existed also in National Women's Hospital (NWH), Auckland data and if so whether they persisted after controlling for parity and obstetric risk. METHODS: The study population included 43,367 singleton, cephalic deliveries, not preceded by caesarean section at NWH from 1992-1999. Ethnicity was Maori, Pacific Island, or other. Obstetric interventions were explored at two time points: (1) at the initiation of the delivery process: induction of labour, prelabour caesarean section, or spontaneous onset of labour; and (2) at the point of delivery: either caesarean section, operative vaginal delivery, or spontaneous vaginal birth. Independent associations were found by fitting polytomous logistic regression models. RESULTS: 10% of the study population were Maori, 19% Pacific Islanders, and 71% other. Unadjusted analyses showed lower rates of all obstetric interventions for Maori and Pacific Island women. Adjusted analyses showed that rates of induction of labour, prelabour caesarean, and operative vaginal delivery were lower for Maori and Pacific women than for all other ethnicities grouped together. However, caesarean delivery rates overall were not different for Maori or Pacific Island women. CONCLUSIONS: The adjusted analysis did not confirm the association seen in the New Zealand Ministry data between ethnicity and caesarean section. However, induction, prelabour caesarean section, and operative vaginal delivery were less common in Maori and Pacific Island women.

Adult↗
PubMed2002

Questioning the indicators of need for obstetric care.

The difficulties in measuring maternal mortality have led to a shift in emphasis from indicators of health to indicators of use of health care services. Furthermore, the recognition that some women need specialist obstetric care to prevent maternal death has led to the search for indicators measuring the met need for obstetric care. Although intuitively appealing, the conceptualization and definition of the need for obstetric care is far from straightforward, and there is relatively little experience so far in the use and interpretation of indicators of service use or need for obstetric care. In this paper we review indicators of service use and need for obstetric care, and briefly discuss data collection issues.

Cesarean Section↗
PubMed2003

[Application of the Unmet Obstetrical Needs method in the III neighborhood of Niamey, Niger (1999)].

West Africa has probably the highest levels of maternal mortality in the world. A new method has been developed by the Institute of Tropical Medicine of Antwerp (Belgium) that gives an estimate of the Uncovered Obstetrical Need. This technique tested in different Western African countries has been now evaluated also in an urban medical district in Niamey, capital of Niger, for the year 1999. The uncovered obstetrical need has been estimated at 15 major Obstetrical Interventions for this period; this means that 15 pregnant women didn't undergo a major surgical intervention necessary to save their life and that they probably died because of this non-intervention. We met quite a lot of problems with this new method: (i) the first problem is related to the difficulty to obtain correct demographic information: it is very difficult to estimate population growth in urban african areas, present population and number of attended births. (ii) The second difficulty came from sociocultural habits: primipare women in Niger go back to their family to deliver (and the place where their family lives is not necessarily the same as the place where they stay with their husband); it is quite possible that a number of primipare women needing a major surgical intervention didn't undergo this intervention because they delivered in their home village (and perhaps died there). (iii) At last, the estimation of a reference rate (calculated at 0.9% for Niger) implies that all women needing a major obstetrical intervention in Niamey, and having a theoretical easy access to medical infrastructures (first line as second line hospitals) present themselves when having a major obstetrical problem. This is probably "wishful thinking". The interest of this new method lies in the fact that it is a cheap technique and easy to put into practice ... provided that one disposes of medical infrastructures that collect correctly all necessary medical information.

Birth Rate↗
PubMedDate not supplied

[A study of the unmet needs for major obstetric interventions: the experience of Burkina Faso].

The fight against maternal mortality requires strategies adapted to every socio-economic and geographic context. To define these strategies, it is essential to have relevant information and to obtain the participation of the various actors involved. One of the indicators which summarizes the maternal mortality level and which it the basis for the mobilization of resources is the maternal mortality ratio. This ratio remains difficult to measure especially in countries with limited resources. Based on the major obstetric interventions for absolute maternal indications, the unmet needs for major obstetric intervention approach is an opportunity for developing countries. We applied this approach in Burkina Faso i) to determine the number of major obstetric interventions for absolute maternal indications carried out in 1998; ii) to quantify the deficit in major obstetric interventions for absolute maternal indications carried out in 1998. In order to do this, we conducted a retrospective study based on files in four sanitary regions. Once the data was collected, we listed 610 major obstetric interventions for absolute maternal indications (IOM/IMA). For the same period, the expected number of IOM/IMA was of 1,470, i.e. a relative global deficit of 58.5%. The analysis per sanitary district revealed disparities with deficits going from 87.5% to 15.5%. The lack of qualified personnel and of surgical infrastructures, the low economic level of the populations and the high cost of the services were identified as factors having favoured these deficits.

Burkina Faso↗
PubMedDate not supplied

One state's response to the malpractice insurance crisis: North Carolina's Rural Obstetrical Care Incentive Program.

In the period 1985-89, there was a severe drop in obstetrical services in rural areas of North Carolina, partly because of rising malpractice insurance rates. The State government responded with the Rural Obstetrical Care Incentive (ROCI) Program that provides a malpractice insurance subsidy of up to $6,500 per participating physician per year. Enacted into law in 1988, the ROCI Program was expanded in 1991, making certified nurse midwives eligible to receive subsidies of up to $3,000 per year. To participate, practitioners must provide obstetrical care to all women, regardless of their ability to pay for services. Total funding for the program has increased from $240,000 to $840,000, in spite of extreme budgetary constraints faced by the State. The program and how its implementation has maintained or increased access to obstetrical care in participating counties are described on the basis of site visits to local health departments in participating counties and data from the North Carolina Division of Maternal and Child Health. The program is of significance to policy makers nationwide as both a response to rising malpractice insurance rates and reduced access to obstetrical care in rural areas, and as an innovative, nontraditional State program in which the locus of decision making is at the county level.

Female↗
PubMed2003

[Recommendations to improve quality of obstetrics care].

The maternal care represents 50 percent of surgical and medical interventions in México. Around 80% of the maternal deaths are foreseeable with actions as risk-managed prenatal care. Prevention of these complications are difficult and require of a competent obstetrician to handle them appropriate. Some assays calculate about 46.4% of maternal deaths, as related to professional responsibility, and 9.7% with hospital responsibility. In México, obstetric malpractice complaints are the most frequent, and reached 14.5% of total matters received by the National Commission of Medical Arbitration (CONAMED) between 1996 and 2001. We analyzed 121 cases concluded, specifically obstetrics-related, requested to the Commission between 1996 and 2001, to identify moments and factors of the medical attention, linked to obstetric claims. Most prominent finds were: high risk pregnancies in 57%, prior cesarean section 22%, hospital income by labor in 28%. Complications were fetal death 25%, obstetric trauma and perinatal asphyxia 12% each one. Births ocurred by cesarean in 37%. Perinatal mortality was 39% and maternal mortality in 33%. The principal deviation was deficient care of labor. They were observed medical patient communication deficiencies in 76%, incomplete expedients in 45%, ethics deviations in 30%, and malpractice in 55%. Whole this information was presented to gynaecologist leaders of opinion: speciality Council, medical associations, public and private hospitals representatives. The conclusion were Nine recommendations to improve the patients care during the pregnancy, labor and postpartum: 1) Pregnancy, labor and postpartum should be attended by personnel qualified and properly authorized; 2) Value integrally each case during the prenatal care and identify high risk patients; 3) Tighten the prenatal care during the third quarter of the gestation; 4) Provide the best obstetric care; 5) Establish best way for each birth; 6) Reduce unnecessary risks; 7) Watch narrowly all patients during the immediate postpartum; 8) Document all the process of attention; 9) Promote and facilitate health education to pregnant patients and their relatives on the gestation inherent risks.

Female↗
PubMed2004

[Course of twin pregnancies and labors in the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw].

DESIGN: The aim of the study was to analyze the course of twin pregnancies and labors in the I Department of Obstetrics and Gynaecology, Medical University of Warsaw. MATERIALS AND METHODS: 124 cases of multiple pregnancy and labor that occurred in the I Department of Obstetrics and Gynecology within the period from 1994 to 2001 were retrospectively analyzed. RESULTS: The study revealed high risk of premature labor, premature rupture of the membranes (PROM), intrauterine growth retardation (IUGR) and pregnancy induced hypertension (PIH) in twin pregnancy. High incidence of cesarean sections was seen both in premature and at-term labors. Significant differences between the mean birth weight and Apgar score of I and II twin were observed. Differences in condition of the neonates were smaller in the group of twins born by cesarean section. CONCLUSIONS: The higher incidence of both obstetrical complications and cesarean sections is associated with twin pregnancies. An increased obstetrical risk and lower Apgar score are observed in case of vaginal delivery of the second twin. Cesarean section seems to improve obstetric results and diminish the differences in condition between the neonates.

Academies and Institutes↗
PubMed2006

Obstetric hysterectomy: a 14-year experience of Rajavithi Hospital 1989-2002.

OBJECTIVES: To review and compare the incidence rate of obstetric hysterectomised patients between two seven-year periods. Theperiods were from October 1, 1988 to September 30, 1995 andfrom October P', 1995 to September 30th, 2002. The data included demographic characteristics, indications, possible risk factors, complications, and operative managements. MATERIAL AND METHOD: Retrospective analysis of the data that was collected from medical and labor records of the obstetric hysterectomised patientsfrom October 1, 1995 to September 30, 2002, the second seven-year period, compared with those in Pratumthong and Wattanaruangkowit's study from October 1, 1988 to September 30, 1995, the first seven-year period. RESULTS: Between 1998 and 2002, there were 201, 696 total deliveries with 111 obstetric hysterectomies. A significant increase in the average incidence rate of hysterectomy from 0.42 to 0.76/1000 deliveries and maternal age, placenta previa and blood transfusion in the second period compared with the first period (p < 0.05). Postoperative complications and the other risk factors of obstetric hysterectomy were not significant difference. CONCLUSION: The present study of obstetric hysterectomy demonstrates a significant increase in the incidence of hysterectomised rate, maternal age, blood transfusion, and placenta previa in the second period compared with the first period.

Blood Transfusion↗
PubMed1991

Characteristics of physicians with obstetric malpractice claims experience.

This study compared the demographic and practice characteristics of physicians with and without obstetric malpractice experience. The sample consisted of 387 family physicians and 204 obstetricians in Washington state who were insured for obstetrics by a major malpractice carrier between January 1982 and June 1988. Fifty-three physicians (9%) had an obstetric malpractice claim during the study period. The approximate overall rate of obstetric malpractice claims was low: 0.32 per 1000 deliveries. The higher the total delivery volume (exposure), the greater the chance of having malpractice experience. Although physicians with practices of over 200 deliveries per year were more likely to have had malpractice experience, their risk of malpractice experience per delivery was lower than that of providers doing fewer than 200 deliveries per year. Our work suggests that insurers might consider basing obstetric malpractice premiums on numbers of deliveries rather than specialty.

Female↗
PubMed1991

Impact of a family physician-staffed maternity center on obstetric services in a rural region.

In the past few years rural hospitals have found obstetric care increasingly difficult to provide. A trend toward family physicians abandoning the practice of obstetrics has been a major obstacle for these hospitals. Malpractice cost and pressures, professional isolation, and inadequate training have all been cited as reasons that family physicians in rural areas have stopped delivering babies. Faced with a large number of women giving birth without prenatal care, a hospital in eastern Kentucky began a regional primary care obstetric unit to assure that obstetric care would be available to all patients who needed it. The hospital chose to staff the maternity center with family physicians so it could offer a family-centered obstetric program and newborn care. Since the opening of the maternity center in 1985, hospital deliveries have increased over 30%, while the percentage of patients who give birth without prenatal care has fallen from 3.0% to 0.7%. This report describes the factors behind the creation of the maternity center, its effect on the hospital, and its effect on the family physicians who serve on its staff.

Adolescent↗